Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Table 1 Advantages and limitations of the different modalities

	Advantages	Limitations
Through-the-scope clips	Multiple sizes available; ease of access; well studied	Not suitable for large lesions or defects as can have slippage or incomplete closure; deployment challenging in certain locations (e.g., duodenal sweep)
Thermal therapy	Ease of access; well studied; compatible with other modalities (e.g., injections, clips)	Potential perforation; delayed bleeding
Injections (epinephrine, sclerosing agents)	Cost-effective; fast onset; well studied; compatible with other modalities (e.g., thermal therapy, clips)	Higher risk of rebleeding if used as monotherapy; localized tissue necrosis and ulceration; limited efficacy for larger lesions; Potential systemic side effects (e.g., tachycardia and arrhythmia with epinephrine)
Over-the-scope clips	Grasp large area; approved for perforation and fistula closures; durability; lower risk of rebleeding compared to traditional therapies	Must remove endoscope to attach application cap; difficulty positioning on target lesion; limited options for further hemostatic intervention after deployment; can be challenging to remove
Hemostatic agents	Ease of application: No direct targeting needed; application to large area in short time; lower risk of tissue damage	Device malfunction: Catheter clog, early activation of powder, washing away powder; contraindicated if history of fistula; can cause biliary obstruction; risk of rebleeding after days; limited penetration of deeper lesions
Endoscopic doppler probe	Real-time evaluation of vasculature; can assess for risk of rebleeding; distinguish arterial vs venous blood flow	Variability in doppler signal interpretation; false signals from cardiac pulsations
Endoscopic ultrasound	Can visualize small vessels not seen on radiologic exam; can concurrently assess submucosal anatomy (e.g., tumor depth, etc.); real-time evaluation of vasculature; can assess for risk of rebleeding; distinguish arterial vs venous blood flow	Need for training in endosonography; limited portability; imaging artifacts from retained blood; not standardized for use in non-variceal GI bleeding

Table 2 United States Food and Drug Administration indications for hemostatic agents

	Forrest Ia	Forrest IB	Forrest IC	Forrest IIa	Forrest IIb	Forrest IIc	Forrest III	Lower GI bleeding
Hemospray	x	x	x	x	x	x	x	x
Nexpowder	x	x	x	x	x	x	x
PuraStat		x	x	x	x	x	x	x
EndoClot		x	x	x	x	x	x	x

GI: Gastrointestinal.